[Intraoperative neurophysiological monitoring in Spain: its beginnings, current situation and future prospects]. / Monitorizacion neurofisiologica intraoperatoria en España: inicios, situacion actual y perspectivas de futuro.

Intraoperative neurophysiological monitoring (IONM) is nowadays another tool within the operating room that seeks to avoid neurological sequels derived from the surgical act. The Spanish Neurophysiological Intra-Surgical Monitoring Association (AMINE) in collaboration with the Spanish Society of Clinical Neurophysiology (SENFC), and the IONM Working Group of the SENFC has been collecting data in order to know the current situation of the IONM in Spain by hospitals, autonomous communities including the autonomous cities of Ceuta and Melilla, the opinions of the specialists in clinical neurophysiology involved in this topic and further forecasts regarding IONM. The data was gathered from November 2015 to May 2016 through telephone contact and/or email with specialists in clinical neurophysiology of the public National Health System, and through a computerized survey that also includes private healthcare centers. With the data obtained, from the perspective of AMINE and the SENFC we consider that nowadays the field of medicine covered by IONM is considerably large and it is foreseen that it will continue to grow. Therefore, a greater number of specialists in Clinical Neurophysiology will be required, as well as the need for specific training within the specialty that involves increasing the training period of MIRs based on competencies due to the increase in techniques/procedures, as well as its complexity.

TITLE: Monitorizacion neurofisiologica intraoperatoria en España: inicios, situacion actual y perspectivas de futuro.La monitorizacion neurofisiologica intraoperatoria (MNIO) es hoy en dia una herramienta mas dentro del quirofano que busca evitar secuelas neurologicas derivadas del acto quirurgico. Nuestro objetivo, desde la Asociacion de Monitorizacion Intraquirurgica Neurofisiologica Española (AMINE), en colaboracion con la Sociedad Española de Neurofisiologia Clinica (SENFC) y el Grupo de Trabajo de MNIO de la SENFC, ha sido recopilar datos para conocer la situacion actual de la MNIO en España por hospitales, comunidades autonomas y ciudades autonomas de Ceuta y Melilla, las opiniones de los especialistas en neurofisiologia clinica involucrados en este tema y las perspectivas de futuro. La recopilacion de los datos se ha realizado durante el periodo de noviembre de 2015 a mayo de 2016 mediante contacto telefonico o correo electronico con especialistas de neurofisiologia clinica del Sistema Nacional de Salud, y mediante una encuesta via informatica en la que tambien participaron algunos centros sanitarios privados. Con los datos obtenidos consideramos desde la perspectiva de la AMINE y la SENFC que el campo de la medicina que abarca la MNIO en estos momentos es muy amplio y seguira creciendo. Por eso, se precisa un mayor numero de especialistas en neurofisiologia clinica, asi como una mayor formacion especifica dentro de la especialidad, que implica incrementar el periodo formativo actual de los medicos internos residentes en funcion a competencias debido al incremento de las tecnicas/procedimientos, asi como su complejidad.

[Treatment of a giant serpentine type middle cerebral artery aneurysm with a high-flow bypass from the petrous internal carotid artery]. / Tratamiento de un aneurisma serpentino gigante de arteria cerebral media conbypass de alto flujo desde la arteria carótida interna petrosa.

A case report of a giant serpentine type aneurysm arising from the M1 segment of the middle cerebral artery (MCA) treated with a high-flow external saphenous vein graft from the petrous segment of the internal carotid artery is presented. The steps and challenges of this demanding surgical technique are also described. The elements to be taken into consideration in the indication, design and realization of the bypass surgery in the treatment of the MCA aneurysms are discussed.

Tratamiento de un aneurisma serpentino gigante de arteria cerebral media con bypass de alto flujo desde la arteria carótida interna petrosa / Treatment of a giant serpentine type middle cerebral artery aneurysm with a high-flow bypass from the petrous internal carotid artery

Se presenta un caso de aneurisma gigante del segmento M1 de la arteria cerebral media (ACM), de tipo serpentino, tratado mediante bypass de alto flujo con vena safena externa desde la arteria carótida interna petrosa. Se describen los pasos de la cirugía y se destacan las dificultades de la técnica. Se discuten los elementos a considerar en la toma de decisiones para la indicación, diseño y realización del bypass en el tratamiento de los aneurismas de la ACM (AU)

A case report of a giant serpentine type aneurysm arising from the M1 segment of the middle cerebral artery (MCA) treated with a high-flow external saphenous vein graft from the petrous segment of the internal carotid artery is presented. The steps and challenges of this demanding surgical technique are also described. The elements to be taken into consideration in the indication, design and realization of the bypass surgery in the treatment of the MCA aneurysms are discused (AU)

[Treatment of intrinsic brain tumors located in motor eloquent areas. Results of a protocol based in navigation, tractography and neurophysiological monitoring of cortical and subcortical structures]. / Tratamiento de los tumores cerebrales intrínsecos de áreas motoras elocuentes. Resultados de un protocolo basado en la navegación, tractografía y monitorización neurofisiológica de estructuras corticales y subcorticales.

OBJECTIVES: The role of the microsurgical management of intrinsic brain tumors is to maximize the volumetric resection of the tumoral tissue minimizing the postoperative morbidity. The purpose of our paper has been to study the benefits of an original protocol developed for the microsurgical treatment of tumors located in eloquent motor areas where the navigation and electrical stimulation of motor subcortical pathways have been implemented. MATERIALS AND METHODS: A total of 17 patients operated on for resection of cortical or subcortical tumors in motor areas were included in the series. Preoperative planning for multimodal navigation was done integrating anatomic studies, motor functional MRI (f-MRI) and subcortical pathways volumes generated by diffusion tensor imaging (DTI). Intraoperative neuromonitorization included motor mapping by direct cortical and subcortical electrical stimulation (CS and sCS) and localization of the central sulcus using cortical multipolar electrodes and the N20 wave inversion technique. The location of all cortical and subcortical stimulated points with positive motor response was stored in the navigator and correlated with the cortical or subcortical motor functional structures defined preoperatively. RESULTS: The mean tumoral volumetric resection was 89.1±14.2% of the preoperative volume, with a total resection (≥100%) in twelve patients. Preoperatively a total of 58.8% of the patients had some motor deficit, increasing 24 hours after surgery to 76.5% and decreasing to 41.1% a month later. There was a great correlation between anatomic and functional data, both cortically and subcortically. However, in six cases it was not possible to identify the central sulcus and in many cases fMRI gave contradictory information. A total of 52 cortical points submitted to CS had positive motor response, with a positive correlation of 83.7%. Also, a total of 55 subcortical points had positive motor response, being in these cases 7.3±3.1 mm the mean distance from the stimulated point to the subcortical tract. CONCLUSIONS: The integration of preoperative and intraoperative anatomic and functional studies allows a safe functional resection of the brain tumors located in eloquent areas, compared to the tumoral resection based on anatomic imaging studies. Multimodal navigation allows the integration and correlation among preoperative and intraoperative anatomic and functional data. Cortical motor functional areas are anatomically and functionally located preoperatively thanks to MRI and fMRI and subcortical motor pathways with TDI and tractography. Intraoperative confirmation is done with CS and N20 inversion wave for cortical structures and with sCS for subcortical pathways. With this protocol we achieved a mean of 90% of volumetric resection in cortical and subcortical tumors located in eloquent motor areas with an increase of neurological deficits in the immediate postoperative period that significantly decreased one month later. Ongoing studies will define the safe limits for functional resection taking into account the intraoperative brain shift. Finally, it must be demonstrated if this protocol has any benefit for patients concerning disease free or overall survival.

Tratamiento de los tumores cerebrales intrínsecos de áreas motoras elocuentes. Resultados de un protocolo basado en la navegación, tractografía y monitorizaciónneurofisiológica de estructuras corticales y subcorticales / Treatment of intrinsic brain tumors located in motor eloquent areas. results of a protocol based in navegation, tractography and neurophysiological monitoring of cortical and subcortical structures

Objetivos. El papel actual del tratamiento microquirúrgicode los tumores cerebrales intrínsecos se basaen alcanzar la máxima resección volumétrica del tumorminimizando la morbilidad postoperatoria. El propósitodel trabajo es estudiar los beneficios de un protocolodiseñado para tratar tumores localizados en áreaselocuentes motoras, en el que se incluye la navegación yla estimulación de tractos motores subcorticales.Material y métodos. Se han incluido 17 pacientescon tumores corticales y subcorticales de área motoratratados quirúrgicamente. Para la planificación preoperatoriase fusionaron en el sistema de navegaciónestudios anatómicos, de resonancia funcional motora(RNM-f) y los tractos subcorticales generados porestudios de tensor de difusión (DTI). La monitorizaciónintraoperatoria incluía el mapeo motor por estimulacióncortical y subcortical directa (ECD y EsCD) e identificacióndel surco central por inversión de la onda N20con electrodos corticales multipolares. La localizaciónde los puntos con respuesta positiva a la ECD o EsCD secorrelacionaba con las áreas corticales o tractos funcionalesmotores definidos en los estudios preoperatoriosgracias al navegador.Resultados. La resección volumétrica tumoral mediafue del 89.1±14.2% del volumen tumoral calculado enlos estudios preoperatorios, con resección total (≥100%)en doce pacientes. En el preoperatorio había focalidadneurológica deficitaria motora en el 58.8% de lospacientes, que aumentó al 76.5% a las 24 horas de lacirugía y se redujo a los 30 días al 41.1%. Hubo una (..) (AU)

Objectives. The role of the microsurgical managementof intrinsic brain tumors is to maximize the volumetricresection of the tumoral tissue minimizing thepostoperative morbidity. The purpose of our paper hasbeen to study the benefits of an original protocol developedfor the microsurgical treatment of tumors locatedin eloquent motor areas where the navigation and electricalstimulation of motor subcortical pathways havebeen implemented.Materials and methods. A total of 17 patients operatedon for resection of cortical or subcortical tumors inmotor areas were included in the series. Preoperativeplanning for multimodal navigation was done integratinganatomic studies, motor functional MRI (f-MRI)and subcortical pathways volumes generated by diffusiontensor imaging (DTI). Intraoperative neuromonitorizationincluded motor mapping by direct corticaland subcortical electrical stimulation (CS and sCS) andlocalization of the central sulcus using cortical multipolarelectrodes and the N20 wave inversion technique.The location of all cortical and subcortical stimulatedpoints with positive motor response was stored in thenavigator and correlated with the cortical or subcorticalmotor functional structures defined preoperatively.Results. The mean tumoral volumetric resection (..) (AU)